सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311154290

DO NOT SEND THIS PAGE TO NATIONAL TESTING AGENCY (NTA).
THE CANDIDATE IS REQUESTED TO RETAIN THE PRINTOUT OF THE CONFIRMATION PAGE FOR FUTURE REFERENCE.
यितगत योरा (Contact Details) वतमान पता (Present Address)
पता (Premises No/ Name) HINGORIYA ईमेल पता (Email Address) KS8120076229@GMAIL.COM
थानीयता (Locality) DHANDU उप-थानीयता (Sub-Locality)(Optional) NA
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) MADHYA PRADESH िजला (District) Ratlam
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) +91 - 8120076229 NA
No.) (Optional)
िपन कोड (Pin Code) 457226
थायी पता (Permanent Address)
पता (Premises No/ Name) HINGORIYA थानीयता (Locality) DHANDU
उप-थानीयता (Sub-Locality)(Optional): NA दे श (Country) INDIA
राय (State) MADHYA PRADESH िजला (District) Ratlam
िपन कोड (Pin Code) 457226
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's Date
अयथी का नाम (Candidate's Name) KHUSHAL SHARMA 26-01-2006
of Birth)
िपता / अिभभावक का नाम (Father / PREMSHANKAR माता / अिभभावक का नाम (Mother /
MAYA SHARMA
Guardian Name) SHARMA Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 690142785715
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT from
MADHYA PRADESH े णी (Category ) GENERAL
where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You
NO िनवास की जगह ( Place of Residence ) RURAL
Diabetic ? )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual Family
NA 0-100000
are a Pwd Candidate, do you have Income )
benchmark disability)?
योयता परीा म कू ली िशा का मायम (
तैयारी का तरीका ( Mode of Preparation ) Self-Study Medium of schooling in qualifying English
exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए आवे दन कर (Session
के िलए आवे दन (Apply For) B.E./B.Tech Session 1
Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
NOT APPLICABLE Matriculate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others OTHERS
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City 1st
MADHYA PRADESH INDORE
1st Choice ) Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City 2nd
MADHYA PRADESH UJJAIN
2nd Choice ) Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City 3rd
MADHYA PRADESH BHOPAL
3rd Choice ) Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City 4th
MADHYA PRADESH KHANDWA
4th Choice ) Choice )
न प मायम (Question Paper Medium) English
th
10वीं या समक योयता िववरण (10 or equivalent Qualification Details)
 उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Passed 2022
Passing/Appearing)
योयता परीा (Qualifying Exam) 10 th or equivalent कू िलंग का थान (Place of Schooling) Urban
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Private Unaided MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Ratlam कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम phoenix international कू ल / कॉलेज का पता (School / College
jaora ratlam
(School/College name should be as per school Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
51018 19179434
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 466.0 ितशत (Percentage) 77.67
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Appearing 2024
Passing/Appearing)
Senior Secondary School
Examination conducted by
योयता परीा (Qualifying Exam) the National Institute of कू िलंग का थान (Place of Schooling) Urban
Open Schooling with a
minimum of five subjects.
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Private Unaided MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Ratlam कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम phoenix international कू ल / कॉलेज का पता (School / College
jaora ratlam
(School/College name should be as per school Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
51018 NA
Pincode) number as per 12th certificate)
अितिरत जानकािरयां (Additional Details)
या आप जु ड़वा ह और दोनों जे ईई (मे न) - 2024 के िलए आवे दन कर रहे ह
NO
(Are you a Twin and both applying for JEE (MAIN) – 2024)?
आपातकालीन संपक िववरण प (Emergency Contact Details)
दे श (Country) INDIA दे श कोड (Country Code) +91
मोबाइल नंबर (Mobile Number) 9340659282 ईमेल आईडी (Email ID) ksharma1112233@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

PHOTO

SIGNATURE

शु क भु गतान िववरण (Fee Payment Details)

भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) 84107344961
परीा शु क (Exam Fee) 1000.0 लेन-दे न की ितिथ (Date of Transaction) 28-11-2023 12:07:07 PM
शु क जमा िकया गया (Fee Submitted
28-11-2023 12:05:54 PM
On)
घोषणा (Declaration)
I declare that information furnished by me in the application form is true in all respect and nothing is concealed. In case any entry or information is found to
be false, this shall entail automatic cancellation of my admission besides rendering me liable to such actions as deemed fit by the University. I hereby
undertake that I have carefully gone through the eligibility conditions prescribed in the prospectus for the programme. I am applying after satisfying that I
meet the eligibility conditions. If at any stage it is found that I do not fullfill the minimum prescribed criteria, my admission, if granted, shall stand cancelled
and I shall have no right to admission whatsoever.
IP Address : 49.43.6.105 Date of Downloading : 28-11-2023 12:07:13 PM